Healthcare Provider Details

I. General information

NPI: 1720080005
Provider Name (Legal Business Name): CANTON ORTHOTIC LABORATORY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 12TH ST NW
CANTON OH
44703-1927
US

IV. Provider business mailing address

811 12TH ST NW
CANTON OH
44703-1927
US

V. Phone/Fax

Practice location:
  • Phone: 330-454-2081
  • Fax: 330-454-9568
Mailing address:
  • Phone: 330-454-2081
  • Fax: 330-454-9568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateOH

VIII. Authorized Official

Name: MR. STEPHEN THOMAS SIMKO
Title or Position: PRESIDENT/LICENSED ORTHOTIST
Credential: LO
Phone: 330-454-2081